Prepared for: The Office of the National Coordinator for Health Information Technology (ONC) and The and Mental Health Services Administration (SAMHSA)

ONC-SAMHSA Behavioral Health Clinical Quality Measure Initiative

Technical Expert Panel Results for Behavioral Health Domain – Trauma

September 26, 2012 by The MITRE Corporation

MITRE 7515 Colshire Drive McLean, VA 22102 Executive Summary

Background The Office of the National Coordinator for Health Information Technology (ONC) and the Substance Abuse and Mental Health Services Administration (SAMHSA) engaged The MITRE Corporation to support the development of a portfolio of Behavioral Health (BH) Clinical Quality Measures (CQMs). This portfolio of BH CQMs are under consideration for future stages of the Centers for Medicare & Medicaid Services (CMS) Incentive Program for the Meaningful Use of Health Information Technology (“Meaningful Use”), which is part of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. This engagement was comprised of two phases: 1. Electronic specification (eSpecification) of prioritized BH CQMs under consideration for future stages of the Meaningful Use (MU) program 2. Development and facilitation of a Technical Expert Panel (TEP) of public and private BH specialists for the purpose of identifying and prioritizing recommendations for future development of BH related CQMs This report presents results of the BH CQM Project Phase 2 (TEP Phase 1) effort for the Trauma BH domain.

Process A TEP composed of public and private sector BH experts, representing the clinical domains of Alcohol Use, , , Drug Use, Suicide, and Trauma, was recruited, assembled, and facilitated over a 4-month period named “TEP Phase 1” from April through July 2012. Through the course of deliberations, the TEP was briefed on the MU program requirements and informed of the CQM development process, including clinical research, measure logic development, National Quality Forum (NQF) endorsement, and eSpecification creation. In a three-meeting weekly rotating cycle, each clinical domain was evaluated for the existence of CQMs included in the MU Stage 1 Final Rule, the MU Stage 2 Notice of Proposed Rulemaking (NPRM) and MU Stage 2 Final Rule, and those eSpecified as part of Project Phase 1. Additionally, the TEP reviewed results of environmental scans for the existence of measures not endorsed by the NQF and clinical literature searches for evidence warranting new measure development. A “TEP Phase 2” focused for an additional three months from July through September 2012 on the topics of Depression Trended Outcome measurement and Drug Use/Prescription Drug Misuse measures.

Results Table 1 provides an overview of the ONC-SAMHSA BH TEP’s research activities and recommendations related to developing a BH CQM for the Trauma domain.

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ONC SAMHSA TEP Results for Behavioral Health Domain – Trauma i by The MITRE Corporation Table 1. Behavioral Health Domain: Trauma

Source Result Domain specific NQF endorsed measures No measures prioritized from Phase 1 of the BH CQM project Meaningful Use Stage 1—Final Rule No measures related to this clinical domain Meaningful Use Stage 2 –Final Rule No measures related to this clinical domain NQF endorsed measures – future No measures related to this clinical domain consideration Non-endorsed Measures (Agency for 22 measures related to this clinical domain were reviewed by Healthcare Research and Quality [AHRQ] TEP, three measures recommended for further development Database) Clinical Evidence 48 articlescovering three broad areas:* • Post-Traumatic Syndrome (PTSD) Trauma Exposure (Non-Veteran-Specific) • Interpersonal Violence • Childhood Violence/PTSD

* Citations were repeated when findings applied to more than one topic area.

Recommendations Based on these activities, the Trauma subgroup recommends: Further development to support retooling and NQF endorsement of the measures below: • NQMC: 006054 (Veterans Health Administration [VHA]) • NQMC: 006052 (VHA) • NQMC: 001734 Family Violence Prevention Fund Future research and development for CQMs for: • PTSD - Adult/Childhood • Interpersonal Violence The following report provides details concerning the ONC-SAMHSA BH TEP activities and recommendations for the Trauma BH clinical domain.

ONC SAMHSA TEP Results for Behavioral Health Domain – Trauma ii by The MITRE Corporation Table of Contents 1 Background ...... 1 2 Project Overview ...... 1 2.1 Technical Expert Panel ...... 2 2.2 Purpose and Activities of the TEP ...... 3 2.3 Common Themes in CQM Development for Behavioral Health ...... 3 3 Domain-Specific Results: Trauma ...... 4 3.1 Environmental Scan Results ...... 4 4 Future Recommendations ...... 7 5 Conclusion ...... 9 Appendix A TEP Member List ...... 10 Appendix B Meeting Schedule...... 12 Appendix C Environmental Scans ...... 13 C.1 NQF-Endorsed Measures - None for the Trauma Domain ...... 13 C.2 AHRQ Measures (Non-NQF-Endorsed) ...... 14 C.3 Clinical Literature Search Matrix ...... 22 C.4 Clinical Literature Search Summary Document ...... 34 Acronyms ...... 35

List of Tables Table 1. Behavioral Health Domain: Trauma ...... ii Table 2. TEP Goals and Literature Reviews ...... 4 Table 3. Literature Search Results and Findings ...... 5 Table 4. Behavioral Health Domain: Trauma - CURRENT POLICY ...... 6 Table 5. Behavioral Health Domain: Trauma - FUTURE RECOMMENDATIONS ...... 6

ONC SAMHSA TEP Results for Behavioral Health Domain – Trauma iii by The MITRE Corporation 1 Background Through the American Recovery and Reinvestment Act of 2009 (ARRA) Health Information Technology for Economic and Clinical Health (HITECH) Act, the Centers for Medicare & Medicaid Services (CMS) is authorized to provide reimbursement incentives for eligible professionals and hospitals for the Meaningful Use (MU) of certified Electronic Health Record (EHR) technology. The Office of the National Coordinator for Health Information Technology (ONC), through an agreement with CMS, has been tasked with developing a portfolio of Clinical Quality Measures (CQM) that capitalizes on the clinical data captured through EHRs for inclusion in the CMS EHR MU Incentive Program. The Behavioral Health Coordinating Committee at the U.S. Department of Health and Human Services (DHHS), with support from the Office of National Drug Control Policy (ONDCP) Demand Reduction Interagency Workgroup EHR subcommittee, submitted consensus recommendations to the ONC, for behavioral health-relevant clinical quality measures to be included in Stage 2 of the MU incentive program. In July 2011, the ONC Federal Advisory Health Information Technology Policy Committee (HITPC) recommended to ONC that these measures be further developed. SAMHSA and ONC jointly sponsored this project to follow up on these recommendations by developing and electronically specifying (eSpecification) BH CQMs to be added to the current EHR CQM portfolio of measures. The principal audience for these measures is primary care MU Eligible Professionals and Eligible Hospitals, although they may also be applicable to a broader range of BH professionals. The scope of the resulting BH eMeasure (BHeM) effort included strategic, technical, facilitation, coordination, clinical, and project management support for the development of a portfolio of electronically specified BH CQMs for potential inclusion in future stages of the CMS EHR MU Incentive Program. BH CQMs for this project are focused in the clinical domains of: • Alcohol Use • Autism • Depression • Drug Use • Suicide • Trauma This report presents results of the BH CQM Project Phase 2 Technical Expert Panel (TEP) for the Trauma BH domain.

2 Project Overview The ONC and SAMHSA engaged The MITRE Corporation to support the development of a portfolio of BH CQMs suitable for inclusion in future stages of the CMS Incentive Program for the Meaningful Use of Health Information Technology (“Meaningful Use”), which is part of the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH). This engagement included two phases:

ONC SAMHSA TEP Results for Behavioral Health Domain – Trauma 1 by The MITRE Corporation Phase 1 - eSpecification of BH CQMs suitable for future stages of the MU program. Ten BH CQMs were eSpecified through this project and include: • National Committee for Quality Assurance (NCQA) 1. NQF #0576, Follow-Up After Hospitalization for Mental Illness 2. NQF #1401, Maternal Depression Screening 3. NQF #1406, Risky Behavior Assessment or Counseling by Age 13 4. NQF #1507, Risky Behavior Assessment or Counseling by Age 18 • The Joint Commission (TJC): 5. NQF #1661, SUB-1 Alcohol Use Screening 6. NQF #1663, SUB-2 Alcohol Use Brief Intervention Provided • Center for Quality Assessment and Improvement in Mental Health (CQAIMH): 7. NQF #0109, and Major Depression: Assessment for Manic or Hypomanic Behaviors 8. NQF#0110, Bipolar Disorder and Major Depression: Appraisal for Alcohol or Chemical Substance Use 9. NQF #0111, Bipolar Disorder: Appraisal for Risk of Suicide • Resolution Health, Inc. (RHI) 10. NQF # 0580, Bipolar Antimanic Agent Note: CQMs NQF #0110 and #1401 were included in MU Stage 2 Final Rule Phase 2 - Development and facilitation of a TEP of public and pri vate BH specialists for the purpose of identifying and prioritizing recommendations for potential new measures for future development.

2.1 Technical Expert Panel A TEP composed of public and private sector BH experts, representing the clinical domains of Alcohol Use, Autism, Depression, Drug Use, Suicide, and Trauma, was recruited, assembled, and facilitated over a 4-month period named “TEP Phase 1” from April through July 2012. Through the course of deliberations, the TEP was briefed on the MU program requirements and informed of the CQM development process, including clinical research, measure logic development, National Quality Forum (NQF) endorsement, and eSpecification creation. In a three-meeting weekly rotating cycle, each clinical domain was evaluated for the existence of CQMs included in the MU Stage 1 Final Rule, the MU Stage 2 Notice of Proposed Rulemaking (NPRM), and those eSpecified as part of Project Phase 1. Additionally, the TEP reviewed results of environmental scans for the existence of measures not endorsed by the NQF and clinical literature searches for evidence warranting measure development. A “TEP Phase 2” focused for an additional three months from July through September 2012 on the topics of Depression Trended Outcome and Drug Use/Prescription Drug Misuse measures. A list of all TEP members is included in Appendix A.

ONC SAMHSA TEP Results for Behavioral Health Domain – Trauma 2 by The MITRE Corporation 2.2 Purpose and Activities of the TEP The purpose of the ONC-SAMHSA BH TEP was to: • Recommend BH clinical quality measures for widespread adoption and use in future stages of the EHR MU Incentive Program • Recommend future measure development needs by evaluating available clinical research • Provide private sector input regarding the feasibility of measure implementation Over the course of the project the TEP completed a comprehensive review of existing BH- relevant CQMs including measures that are NQF endorsed, community measures in the Agency for Healthcare Research and Quality measure clearinghouse, and measures that were under development through similar federal initiatives. In addition, for each domain, the TEP reviewed the clinical literature to evaluate the state of the field of measure development and to make recommendations on the next steps for measure development. A listing of all scheduled meetings and topics is included in Appendix B. Copies of the environmental scans are included in Appendix C. SAMHSA is currently developing a National Behavioral Health Quality Framework. The framework is aligned with the National Quality Strategy and will prioritize six goals; (1) evidence-based prevention, treatment and recovery, (2) person and family-centered care, (3) coordination of behavioral health and other health care, (4) health living, (5) safe care, and (6) accessible and affordable care. The recommendations from the Technical Expert Panel are focused on measure recommendations for the Meaningful Use EHR incentive program and are primarily applicable to primary care and general hospital settings. These recommendations will be considered in the broad portfolio of SAMHSA quality work, including development of the framework and future measure development activities.

2.3 Common Themes in CQM Development for Behavioral Health Many common themes emerged in the TEP discussions across the six domains. The United States (U.S.) healthcare system is evolving rapidly. The widespread use of standardized data captured in EHRs has profound potential to improve quality measurement in both research and healthcare contexts. Our discussions highlighted some principles related to BH quality measures development for consideration in efforts to realize this potential.

Standardized, Validated Screening and Assessment Tools Significant discussion focused on the use of valid tools for screening, assessment, and outcome monitoring for BH diagnoses. Many standardized assessment tools exist for any given BH condition. There is often no ‘gold standard’ assessment tool for a given purpose. As a result, measure developers often specify the use of ‘a valid instrument’. This can create complications for the e-specification of the measure and for data comparison across sites. However, while standards may be useful for exchanging data, mandating the use of a specific instrument may limit a provider’s ability to select tools that they prefer, or develop new, innovative approaches to screening and assessment. Development of standards for the endorsement of validated tools, as well as standard processes for calibrating tools to a standard scale would be incredibly

ONC SAMHSA TEP Results for Behavioral Health Domain – Trauma 3 by The MITRE Corporation valuable for improving the quality and interoperability of data while allowing the field to evolve with the state of the science.

Comprehensive Measure Sets For each of the six domains TEP members discussed the long range goal of developing measure sets that support evidence based practices across the full continuum of care. For most BH disorders addressed in primary care settings this includes prevention, screening, follow up assessments, screening for co-morbid conditions, primary care based intervention, referral management, care coordination, and outcome tracking. For many of the domains addressed in this project the state of the research does not yet support the development of CQMs for each of these purposes. However, it was useful to consider the current state of measure development within this context to make recommendations for the next stages of measure development.

Implementation in Real World Settings TEP discussions also highlighted the need to consider measure development in the context of real world healthcare settings. Our national healthcare system is rapidly evolving and health reform is putting significant pressure on primary care providers. The efficacy of primary care based interventions for behavioral disorders is highly dependent on implementation which can be influenced by acceptability to providers, ability to integrate best practices into their workflow, provider attitudes and comfort level with the intervention, etc. The TEP highlighted the need for additional research to address the implementation barriers that exist in busy practices, including technologies that reduce patient and provider burden, to identify methods for addressing patients with multiple BH co-morbidities, and to determine how clinical decision support can be tied to CQMs in EHR systems.

3 Domain-Specific Results: Trauma 3.1 Environmental Scan Results MITRE engaged The Cloudburst Group as the subcontractor for the clinical literature review process due to their expertise in completing and analyzing clinical literature research in the six key domains of Alcohol, Substance Abuse, Depression, Suicide, Trauma and Autism. The Cloudburst Group deliverables were aligned with the goals of each TEP meeting (see Table 2).

Table 2. TEP Goals and Literature Reviews

TEP Phase 1 – Goal (All 6 Domains) Literature Review Deliverables Meeting 1 - Orientation and Familiarity with Current TEP participation and orientation if available Measures Meeting 2 - Non-Endorsed Measures Delivery of Phase 1 environmental scan literature review Recommendations/Lit Search Question Formation domain-specific search questions for all 6 domains and participation in weekly TEPs Meeting 3 - Select Promising Clinical Research Delivery of final results from Phase 1 environmental scan of all 6 domains and participation in weekly TEPs

ONC SAMHSA TEP Results for Behavioral Health Domain – Trauma 4 by The MITRE Corporation The Cloudburst Group provided literature search questions for review with the TEP at each Phase 1, Meeting 2 discussion. These questions were based on a preliminary review of ongoing research that could inform the development or retooling of each proposed measure or the creation of new measures. The answers to these questions and additional comments from the TEP members in the Meeting 2 discussions were used to generate the search criteria for the environmental scans. The results of these scans were then summarized and presented to each TEP in an executive summary (Table 3). The most appropriate articles were then collated for each domain and presented in a literature matrix (see Appendix C).

Recommended Search Terms for Trauma Literature Scan: • Trauma Exposure and screening, primary care (PC) • Post-Traumatic Stress Disorder (PTSD) screening tools • Interpersonal violence screenings • Childhood Violence screening • Trauma screening treatment primary care • Trauma screening clinical guideline • Primary care trauma screen • Traumatic brain injury screen • Trauma measures primary care • National Center for PTSD • Trauma assessment • Trauma exposure measures • Trauma symptom inventory • Screen interpersonal violence primary care • Screen/measure adverse childhood event • Screen child trauma primary care • Clinical decision rules [trauma screening; PTSD screening; and trauma] Below is a high-level summary of the 48 total results divided under 3 broad areas. The full matrix including summaries of each of the citations is available in Appendix C of this paper.

Table 3. Literature Search Results and Findings

Topics / Summary of Findings Search Focus Area PTSD/Trauma Exposure • PTSD is diagnosed only about 50% of the time – and less for those with co- (non-Vet) occurring disorders. • Gold standard assessment tools include the Clinician-Administered PTSD Scale and the Structured Clinical Interview for DSM-IV, PTSD module. Use of these in clinical practice is limited by length and need for administration by a trained clinician. • There are a wide range of self-report PTSD assessments though there is no “gold standard” among them. The Impact Events Scale (IES), PTSD Checklist – Civilian Version, Trauma Screening Questionnaire (TSQ), and Self-Report Inventory of PTSD have the best diagnostic properties.

ONC SAMHSA TEP Results for Behavioral Health Domain – Trauma 5 by The MITRE Corporation Topics / Summary of Findings Search Focus Area Interpersonal Violence (IPV) • Many professional organizations recommend universal screening for IPV (especially for women), there is no consensus that this is appropriate and/or that there is sufficient evidence to warrant universal screening. • There is no “gold standard” screener – all have limitations on psychometric properties but for healthcare settings the Hurts, Insults, Threatens, and Screams (HITS) Scale screener may be the best current option. Childhood Violence/PTSD • Studies show large proportion of adults in primary care settings (20-50%) have (physical or sexual) histories of child physical or sexual abuse. • No agreed upon guidelines for screening and no “gold standard” screener.

3.2 Measure Recommendations Table 4 provides an overview of current trauma related measures included in the MU program. Table 5 includes an overview of the ONC-SAMHSA BH TEP’s recommendations related to developing a BH CQM for the Trauma domain.

Table 4. Behavioral Health Domain: Trauma - CURRENT POLICY

Source Result Meaningful Use Stage -Final Rule No measures related to this clinical domain Meaningful Use Stage 2-Final Rule No proposed measures related to this clinical domain

Table 5. Behavioral Health Domain: Trauma - FUTURE RECOMMENDATIONS

Source Recommendations NQF endorsed measures – future No measures related to this clinical domain consideration Non-endorsed Measures (Agency for Three measures related to this clinical domain recommended for Healthcare Research and Quality [AHRQ] further development Database) • NQMC: 006054 (Veterans Health Administration [VHA])- Percent of patients screened positive for PTSD symptoms with the PC- PTSD with timely disposition • NQMC: 006052 (VHA)- Percent of eligible patients screened at required intervals for PTSD and, if positive PC-PTSD result, who have suicide risk evaluation completed within 24 hours • NQMC: 001734 (Family Violence Prevention Fund)- Domestic violence: percent of adult and adolescent patients who screened positive for current or past intimate partner violence (IPV) and who answered yes to initial danger assessment questions for whom records indicate that a suicide and homicide assessment was conducted Clinical Evidence Recommendations for additional research focused on:* • High risk populations • Symptoms of trauma and comorbidities • Screening and assessment tools for primary care • Identification of childhood trauma • Effective implementation

* Citations were repeated when findings applied to more than one topic area.

ONC SAMHSA TEP Results for Behavioral Health Domain – Trauma 6 by The MITRE Corporation The Trauma domain is in its infancy in terms of overall CQM development appropriate for the MU program. There are currently no NQF endorsed measures developed and/or included in the Stage 1 or Stage 2 Final Rules for MU. The outcome goals of the TEP discussions for this domain were to: • Identify the state of evidence to support trauma screening in the PC setting and the state of available CQMs related to Trauma. • Determine whether there is clear research and data to support the development of a CQM for Trauma. • Determine priority next steps for measure development in this domain. Significant early TEP discussions focused on the definition of trauma. However, for the purposes of this process, the TEP chose to focus on PTSD and interpersonal violence (IPV), since the majority of research is focused on these areas.

Screening for Trauma In 2004, the United States Preventive Services Task Force (USPSTF) reviewed the evidence and found insufficient evidence to recommend routine screening for trauma. The TEP noted that the American Academy of Pediatrics has stated that screening for IPV is critical due to its effects on children. However, after reviewing the current state of the field there was no consensus among TEP members on the utility of a population based screening for trauma. There was, however, strong support for trauma informed care of patients in treatment of BH disorders. In addition, the TEP suggested that measures targeting high-risk groups for screening including criminal justice and court-involved, patients with mental health and substance abuse disorders, homeless, veterans, and patients with HIV may be valuable. The Veterans Health Administration (VHA) and the Indian Health Service (IHS) currently regularly screen for both PTSD and IPV due to the prevalence of trauma in their respective populations and could provide evidence to support the development and endorsement of CQMs for this domain. The VHA and the Family Violence Prevention Fund have created suites of measures to address screening and intervention for PTSD and IPV respectively. These measures could be used as a foundation for creating new measures that target high risk populations. TEP members suggested that research on primary care based screening and interventions focused on specific diagnoses or conditions for which it is important to know of a history of trauma would add great value to the development of future measures targeting high risk populations.

4 Future Recommendations While the focus of this project is to recommend CQMs for the HITECH MU program, the TEP was also asked to make recommendations for additional research and development needed to support the next phases of measure development for this domain.

Additional Research Recommendations While there was clear TEP consensus on the relevance of trauma to health and risk for BH disorders, there was not consensus on the sufficiency of evidence to support universal screening. Some TEP members cited the prevalence of trauma to support universal screening however

ONC SAMHSA TEP Results for Behavioral Health Domain – Trauma 7 by The MITRE Corporation others emphasized that the trauma-health relationship is significantly mediated by mental health symptoms such as PTSD, other anxiety symptoms, and depression. Screening for these conditions could provide the same potential points of intervention as screening for trauma. Future research should evaluate the percentage of patients who would be identified and treated for trauma using a population based screen versus a screen to identify trauma in targeted high risk populations as described above (i.e., would the population based screening capture or identify more patients?). Symptoms of Trauma and Co-morbidities Questions were also raised regarding the value of primary care based intervention for individuals who screen positive for trauma but show no clinical symptoms. TEP members recommended additional research to evaluate the value of screening for trauma in the absence of clinically significant symptoms. Is primary care based intervention valuable for patients without co-morbid BH issues? The primary care system is already overburdened such that any additional screening requirements must be actionable in a way that improves patient outcomes. In addition, TEP members highlighted the need for additional research on the factors that influence response to trauma and resilience. How do symptomatology and resilience differ with age, gender, and culture? TEP members pointed out that not all those who experience trauma are negatively impacted by it; therefore, targeting symptomology could aid in more accurately identifying patients likely to benefit from specific interventions including early intervention efforts to improve resiliency. Screening and Assessment Tools One of the challenges in developing measures for PTSD and IPV is the lack of a clear “gold standard” for screening methods. A summary of screeners and treatment protocols was provided in a clinical literature scan and is attached in Appendix C.3. The TEP recommended additional research focused on identifying valid and reliable screening and assessment tools that are practical for implementation in a primary care setting. Research should also assess unanticipated harms associated with repeated or poorly implemented screening. The TEP also recommended evaluating the value of treating individuals with subclinical PTSD (i.e., those signs/symptoms of trauma exposure that may impact functioning but that don’t meet the clinical criteria for the disorder). Some data suggest that the majority of individuals with false negative PC-PTSD screens have partial PTSD; these individuals could be captured by adjusting thresholds in the PTSD screening protocol. The TEP also recommended additional studies regarding the most relevant time frames to target screening and assessments (e.g., past year vs. lifetime). The sequelae of trauma can be lifelong, though often hidden from detection due to shame, secrecy, and social taboos against exploring certain realms of human experience. However, targeted research should help to define the time frames that are most clinically relevant for a given population. Childhood Trauma A review of the longitudinal research on adverse childhood experiences by Dr. Vincent Felitti (see appendix C.5.2) was shared and discussed with the TEP. This research highlights the long- term impacts on physical and psychological health from adverse experiences in childhood. The American Academy of Pediatrics has stated that screening for IPV is critical due to its effects on

ONC SAMHSA TEP Results for Behavioral Health Domain – Trauma 8 by The MITRE Corporation children. However, the USPSTF, in its recent report to Congress, highlighted the need for additional research into interventions to prevent child abuse and neglect in primary care and acute care settings. The TEP recommends more research into child abuse screening in primary care and hospital settings, where this issue frequently goes unrecognized. Implementation The TEP also recommended additional research regarding implementation of trauma screening in real world settings. This should include trauma screening feasibility and acceptability to providers, adherence to screening and intervention best practices, unanticipated harms of repeat or poorly administered screening, screening efficiency, and long term outcomes. In addition, it is important to address whether the information best gathered by interpersonal interview or by computer/self-administered, and whether this differs across populations (culture, age, sex, type of trauma, etc.). Provider Attitudes Provider attitudes and comfort level with discussing trauma dramatically influence the efficacy of screening and primary care based intervention. Repeated screening for trauma can re- traumatize the victim so it is very important how these systems are implemented. The TEP highlighted the complexity of trauma screening and the need for training and ongoing support to be in place if screenings are conducted. Additional research is needed on the best ways to administer this type of screening in real world settings with physicians who may not be familiar or comfortable with addressing trauma and/or related topics. Future study is also recommended to determine how trauma screening and intervention can be implemented to improve provider attitudes or reduce the influence of the provider on the effectiveness of the process.

5 Conclusion The ONC-SAMHSA Behavioral Health CQM TEP, Trauma domain subgroup, in its quest to recommend CQMs suited for the HITECH Meaningful Use of Health IT Incentive program, determined that while there are currently no NQF endorsed CQMs in the Trauma domain, there are a number of measures that are currently in use in healthcare systems across the country that could be retooled to improve quality in this domain. In addition, significant research is needed to better understand what opportunities exist to advance healthcare quality through addressing trauma in real world ambulatory care settings.

ONC SAMHSA TEP Results for Behavioral Health Domain – Trauma 9 by The MITRE Corporation Appendix A TEP Member List

COMMUNITY MEMBERS

Gavin Bart, MD FACP FASAM, Director, Division of Addiction Medicine, Hennepin County Medical Center Rhonda Beale, MD, Chief Medical Officer, Optum Health Behavioral Solutions Lyndra Bills*, MD, Associate Medical Director, Community Care Behavioral Health Gregory Brown, PhD, University of Pennsylvania Kate Comtois, PhD, MPH, Harborview Medical Center Geraldine Dawson, MD, Chief Science Officer, Autism Speaks Deborah Garnick, ScD, Professor, Institute for Behavioral Health, Brandeis University Frank Ghinassi, PhD, VP, Quality and Performance Improvement, University of Pittsburgh Medical Center, Western Psychiatric Institute and Clinic Eric Goplerud, PhD, Senior VP, NORC at the University of Chicago Rob Gore-Langton, The EMMES Corporation Constance Horgan, PhD, Director, Institute for Behavioral Health, Brandeis University Heller School Anna Mabel Jones, Oxford House, Inc. Alex Krist, MD, MPH, Community Physician Robert Lindblad, MD, Chief Medical Officer, The EMMES Corporation A Thomas McLellan**, PhD, CEO, Treatment Research Institute LaVerne Miller, Policy Research Associates, Delmar, New York Daniel Mullin, PsyD, University of Massachusetts Center for Integrated Primary Care Keris Myrick, President/Chief Executive Officer, Project Return Peer Support Network Charlie Reznikoff, MD, University of Minnesota- Hennepin County Medical Center Lucy Savitz, PhD, Intermountain Healthcare Robert P. Schwartz, MD, Friends Research Institute Cheryl Sharp*, MSW, National Council for Community Behavioral Healthcare Morton Silverman, MD, Senior Advisor, Suicide Prevention Resource Center Piper Svensson-Ranallo, PhD Candidate, University of Minnesota Institute for Health Informatics Thomas Swales, PhD, Assistant Professor of Psychiatry, Case Western Reserve University Amy Wetherby, PhD, Florida State University Charles B. Willis, Project Director, Georgia Mental Health Consumer Network

* delineates member with specific expertise in domain of Trauma ** ad hoc

ONC SAMHSA TEP Results for Behavioral Health Domain – Trauma 10 by The MITRE Corporation FEDERAL AGENCY STAFF

Girma Alemu, HRSA Laura Kavanagh, HRSA Susan Azrin, NIH/NIMH Rachel Kimerling, VA Alex Blum, NIH Jinhee Lee, SAMHSA Maureen Boyle, SAMHSA Charlene LeFauve, SAMHSA Ian Corbridge, HRSA BJ Lide, NIST Frances Cotter, SAMHSA Cheryl Lowman, NIH Beverly Cotton, IHS Katy Lysell, VA Alex Crosby, CDC Richard McKeon, SAMHSA David DeVoursney, SAMHSA Lela McKnight-Eily, CDC Gaya Dowling, NIH/NIDA Mariquita Mullen, HRSA Vivian Faden, NIH/NIAAA Nick Reuter, SAMHSA Carrie Feher, CMS Lauren Richie, ONC Reed Forman, SAMHSA Catherine Rice, CDC/ONDIEH/NCBDDD Udi Ghitza, NIH/NIDA Alex Ross, HRSA Lisa Gilotty, NIH Ken Salyards, SAMHSA Denise Grenier, IHS June Sivilli, ONDCP Alex Harris, VA Camille Smith, CDC/ONDIEH/NCBDDD Yael Harris, HRSA Robert Stephenson, SAMHSA Jennie Harvell, ASPE Betty Tai, NIH/NIDA Mose Herne, IHS Linda Weglicki, NIH/NINR Larke Huang, SAMHSA Rebecca Wolf, CDC/ONDIEH/NCBDDD Alice Kau, NIH/NICHD Elise Young, HRSA

CORE TEAM

TEP LEADS: Maureen Boyle, SAMHSA and Lauren Richie, ONC

SAMHSA ONC Maureen Boyle, PhD Jesse James, MD Westley Clark, MD Kevin Larsen, MD Ken Salyards Anca Tabakova Robert Stephenson Kate Tipping

CMS MITRE Corporation Carrie Feher Beth Halley Nicole Kemper Saul Kravitz Maggie Lohnes Denise Sun Jocelyn Tafalla Pam Thornton Sandy Trakowski

ONC SAMHSA TEP Results for Behavioral Health Domain – Trauma 11 by The MITRE Corporation Appendix B Meeting Schedule

BH CQM TEP Schedule and Topics – Revised 7/6/12 Week # Week of: Topic 1 4/9-4/13 KICK-OFF – OPTION 1: 4/9: 1:00P-3:00P OPTION 2: 4/12: 12:30P–2:30P 2 4/16 3-4:30pm Eastern Suicide/Trauma – Week 1 3 4/23 3-4:30pm Eastern Autism – Week 1 4 4/30 3-4:30pm Eastern Depression – Week 1 5 5/7 3-4:30pm Eastern Drugs/Alcohol – Week 1 6 5/14 3-4:30pm Eastern Suicide/Trauma – Week 2 7 5/21 3-4:30pm Eastern Autism – Week 2 8 5/29 3-4:30pm Eastern Depression – Week 2 9 6/4 3-4:30pm Eastern Drugs/Alcohol – Week 2 10 6/11 3-4:30pm Eastern Suicide/Trauma – Week 3 11 6/22 3-4:30pm Eastern Autism – Week 3 12 6/25 3-4:30pm Eastern Depression – Week 3 13 7/2 3-4:30pm Eastern CANCELLED 14 7/9 3-4:30pm Eastern Drugs/Alcohol – Week 3

TEP PHASE II 15 7/16 3-4:30pm Eastern Depression – Week 1 16 7/23 3-4:30pm Eastern Drug Use/PDM – Week 1 17 7/30 3-4:30pm Eastern Depression – Week 2 * 18 8/6 3-4:30pm Eastern Drug Use/PDM – Week 2 * ADDED 8/9 All day event In person and Webinar 19 8/13 3-4:30pm Eastern Depression – Week 3 * 20 8/20 3-4:30pm Eastern Drug Use/PDM – Week 3 * 21 8/27 3-4:30pm Eastern Depression – Week 4 * 22 9/3 3-4:30pm Eastern Drug Use/PDM – Week 4 * 23 9/10 3-4:30pm Eastern Depression – Week 5 * 24 9/17 3-4:30pm Eastern Drug Use/PDM – Week 5 * *if needed

ONC SAMSHA TEP Results for Behavioral Health Domain – Trauma 12 by The MITRE Corporation Appendix C Environmental Scans

C.1 NQF-Endorsed Measures - None for the Trauma Domain C.2 AHRQ Measures (Non-NQF-Endorsed) C.3 Clinical Literature Search Matrix C.4 Clinical Literature Search Summary Document

ONC SAMSHA TEP Results for Behavioral Health Domain – Trauma 13 by The MITRE Corporation Domain: Trauma (Trauma Screening) – Environmental Scan

Search Criteria: Trauma Full List of Original Results* Screening (*includes NQF endorsed measures) ■ 19 results initially identified – 5 removed (NQF endorsed) Click Here ■ Final pool = 14 results for review

C.2 - AHRQ Measures Non NQF-Endorsed 14 September 26, 2012 ONC SAMSHA TEP Results for Behavioral Health Domain – Trauma © 2012 The MITRE Corporation. All rights Reserved. Domain: Trauma Screening – Top Results

Measure Review Prioritized Result Summary (M= maybe, X=No, Y = yes) 1 M Hospital-based inpatient psychiatric services: the percentage of patients admitted to a hospital-based inpatient psychiatric setting who are screened within the first three days of admission for all of the following: risk of violence to self or others, substance use, psychological trauma history and patient strengths. 2010 Dec. [NQMC Update Pending] NQMC:006322 The Joint Commission - Health Care Accreditation Organization 2 Behavioral health: percent of eligible patients screened at required intervals for PTSD. 2010 Oct. NQMC:006012 Veterans Health Administration - Federal Government Agency [U.S.] 3 Post-traumatic stress disorder (PTSD): percent of Veterans screened positive for PTSD symptoms with the PC-PTSD with disposition. 2010 Oct. NQMC:006055 Veterans Health Administration - Federal Government Agency [U.S.] 4 Post traumatic stress disorder (PTSD): percent of patients screened positive for PTSD Y symptoms with the PC-PTSD with timely disposition. 2010 Oct. NQMC:006054 Veterans Health Administration - Federal Government Agency [U.S.] 5 Post-traumatic stress disorder (PTSD): percent of eligible patients screened at required Y intervals for PTSD and, if positive PC-PTSD result, who have suicide risk evaluation completed within 24 hours. 2010 Oct. NQMC:006052 Veterans Health Administration - Federal Government Agency [U.S.]

C.2 - AHRQ Measures Non NQF-Endorsed 15 September 26, 2012 ONC SAMSHA TEP Results for Behavioral Health Domain – Trauma © 2012 The MITRE Corporation. All rights Reserved. Domain: Trauma (PTSD) – Environmental Scan

Search Criteria: Post Traumatic Full List of Original Results* Stress Disorder and Ambulatory (*includes NQF endorsed measures) ■ 15 results initially identified – 0 removed (NQF endorsed) Click Here ■ Final pool = 15 results for review

C.2 - AHRQ Measures Non NQF-Endorsed 16 September 26, 2012 ONC SAMSHA TEP Results for Behavioral Health Domain – Trauma © 2012 The MITRE Corporation. All rights Reserved. Domain: Trauma (PTSD) – Top Results

Measure Review Prioritized Result Summary (M= maybe, X=No, Y = yes) Behavioral health: percent of eligible patients screened annually for depression AND if positive PHQ-2 or 1 PHQ-9 result or affirmative response to Q9 of the PHQ-9 and percent of eligible patients screened at required intervals for PTSD AND if positive PC-PTSD result, have suicide risk evaluation completed within 24 hours. 2010 Oct. NQMC:006013 Veterans Health Administration - Federal Government Agency Domestic violence: percent of adult and adolescent patients assessed who disclosed that they were 2 victims of abuse. 2004 Feb. NQMC:001435 Family Violence Prevention Fund - Nonprofit Organization Domestic violence: percent of adult and adolescent patients seen by a provider who were assessed for 3 intimate partner violence (IPV) during the last year. 2004 Feb. NQMC:001434 Family Violence Prevention Fund - Nonprofit Organization Domestic violence: percent of adult and adolescent patients who screened negative for current or past 4 intimate partner violence (IPV) but whom the provider is still concerned may be a victim of IPV who were offered information about IPV and referrals. 2004 Feb. NQMC:001736 Family Violence Prevention Fund - Nonprofit Organization Domestic violence: percent of adult and adolescent patients who screened negative for current or past 5 intimate partner violence (IPV) but whom the provider is still concerned may be a victim of IPV whose records include prompts for specific follow-up questions about IPV to occur at the patient's next visit. 2004 Feb. NQMC:001737 Family Violence Prevention Fund - Nonprofit Organization Domestic violence: percent of adult and adolescent patients who screened positive for current or past 6 Y intimate partner violence (IPV) and who answered yes to initial danger assessment questions for whom records indicate that a suicide and homicide assessment was conducted. 2004 Feb. NQMC:001734 Family Violence Prevention Fund - Nonprofit Organization (Continued) C.2 - AHRQ Measures Non NQF-Endorsed 17 September 26, 2012 ONC SAMSHA TEP Results for Behavioral Health Domain – Trauma © 2012 The MITRE Corporation. All rights Reserved. Domain: Trauma (PTSD) – Top Results Cont.

Measure Review Prioritized Result Summary (M= maybe, X=No, Y = yes)

7 Domestic violence: percent of adult and adolescent patients who screened positive for current or past intimate partner violence (IPV) for whom records indicate that specified assessments were conducted. 2004 Feb. NQMC:001733 Family Violence Prevention Fund - Nonprofit Organization 8 Domestic violence: percent of adult and adolescent patients who screened positive for current or past intimate partner violence (IPV) for whom records indicate that specified intervention and treatment plans were offered. 2004 Feb. NQMC:001735 Family Violence Prevention Fund - Nonprofit Organization 9 Domestic violence: percent of providers of health care services to adult and adolescent patients in the clinical setting who documented that they complied with assessment protocols. 2004 Feb. NQMC:001436 Family Violence Prevention Fund - Nonprofit Organization

C.2 - AHRQ Measures Non NQF-Endorsed 18 September 26, 2012 ONC SAMSHA TEP Results for Behavioral Health Domain – Trauma © 2012 The MITRE Corporation. All rights Reserved. Domain: Trauma (Adverse Childhood Experiences) – Environmental Scan

Search Criteria: Adverse Full List of Original Results* Childhood Experiences (*includes NQF endorsed measures) ■ 9 results initially identified – 0 removed (NQF endorsed) Click Here ■ Final pool = 9 results for review

C.2 - AHRQ Measures Non NQF-Endorsed 19 September 26, 2012 ONC SAMSHA TEP Results for Behavioral Health Domain – Trauma © 2012 The MITRE Corporation. All rights Reserved. Domain: Trauma (Adverse Childhood Experience) – Top Results Measure Review Prioritized Result Summary (M= maybe, X=No, Y = yes) Domestic violence: percent of adult and adolescent patients assessed who disclosed that they were victims 1 of abuse. 2004 Feb. NQMC:001435 Family Violence Prevention Fund - Nonprofit Organization Domestic violence: percent of adult and adolescent patients seen by a provider who were assessed for 2 intimate partner violence (IPV) during the last year. 2004 Feb. NQMC:001434 Family Violence Prevention Fund - Nonprofit Organization Domestic violence: percent of adult and adolescent patients who screened negative for current or past 3 intimate partner violence (IPV) but whom the provider is still concerned may be a victim of IPV who were offered information about IPV and referrals. 2004 Feb. NQMC:001736 Family Violence Prevention Fund - Nonprofit Organization Domestic violence: percent of adult and adolescent patients who screened negative for current or past 4 intimate partner violence (IPV) but whom the provider is still concerned may be a victim of IPV whose records include prompts for specific follow-up questions about IPV to occur at the patient's next visit. 2004 Feb. NQMC:001737 Family Violence Prevention Fund - Nonprofit Organization Domestic violence: percent of adult and adolescent patients who screened positive for current or past 5 Y intimate partner violence (IPV) and who answered yes to initial danger assessment questions for whom records indicate that a suicide and homicide assessment was conducted. 2004 Feb. NQMC:001734 Family Violence Prevention Fund - Nonprofit Organization

Domestic violence: percent of adult and adolescent patients who screened positive for current or past 6 intimate partner violence (IPV) for whom records indicate that specified assessments were conducted. 2004 Feb. NQMC:001733 Family Violence Prevention Fund - Nonprofit Organization (Continued) C.2 - AHRQ Measures Non NQF-Endorsed 20 September 26, 2012 ONC SAMSHA TEP Results for Behavioral Health Domain – Trauma © 2012 The MITRE Corporation. All rights Reserved. Domain: Trauma (Adverse Childhood Experiences) – Top Results Cont.

Measure Review Prioritized Result Summary (M= maybe, X=No, Y = yes) 7 Domestic violence: percent of adult and adolescent patients who screened positive for current or past intimate partner violence (IPV) for whom records indicate that specified intervention and treatment plans were offered. 2004 Feb. NQMC:001735 Family Violence Prevention Fund - Nonprofit Organization 8 Domestic violence: percent of providers of health care services to adult and adolescent patients in the clinical setting who documented that they complied with assessment protocols. 2004 Feb. NQMC:001436 Family Violence Prevention Fund - Nonprofit Organization

C.2 - AHRQ Measures Non NQF-Endorsed 21 September 26, 2012 ONC SAMSHA TEP Results for Behavioral Health Domain – Trauma © 2012 The MITRE Corporation. All rights Reserved. Weighted Target Population/Setting Relevance Year of Citation Pub Screening Tool or (Clinical) Risk Universal vs Targeted Evidence of Topic Measure Age Range Setting Group Screening Health Outcomes Key Findings/Implications High Med Low Assessments of Trauma Screeners in Primary Care Settings Trauma Exposure and PTSD Screeners used in Clinical Settings Review Studies 1 Systematic 13 PTSD Screeners reviewed Adults varied varied Universal IES, TSQ performed consistently well; small # of M1 Brewin, C. R. (2005). "Systematic Review of PTSD core symptoms as effective as longer lists; Review of Screening Instruments for Screeners measures with fewer items perform as well as 2005 Adults at Risk of PTSD." Journal of those with more items Traumatic Stress 18(1): 53-62.

2 Self-Report SysReview of 41 Self-Report Adults varied varied Pressing need to develop Developed item bank of 104 measures in interest H1 Assessments of PTSD Screeners quality screener to ensure of developing a CAT (computer adapted test) for PTSD people with PTSD are not PTSD - builds on previous systematic reviews del Vecchio, N., A. R. Elwy, et al. missed - especially those (Brewin, Norris). Only reviewed tools that (2011). "Enhancing Self-Report masked by co-occurring identified multiple types of trauma. No "gold Assessment of PTSD: Development of 2011 disorder, and to ensure those standard" among self-report screeners, but an Item Bank." Journal of Traumatic who do not are not named IES, PTSD Checklist - Civilian Version, Stress 24(2): 191-199. misdiagnosed. TSQ, and Self-Report Inventory of PTSD to have best credentials.

3 Review of Review includes 6 trauma- Adults varied varied PTSD Checklist has excellent and M1 Screening and specific measures: Impact of has been used in variety of settings; IES has Outcomes Events Scale (IES); Primary been tested extensively and has good Measures for Care - PTSD Screener (PC- psychometrics; PC PTSD is very brief and limited Deady, M. (2009). A Review of Alcohol/Drug PTSD); PTSD Checklist; empirical testing; PTSD Symptom Self Report Screening, Assessment and Outcome Settings PTSD Symptom Self Report; has good psychometrics and used in range of Measures for Drug and Alcohol 2009 Traumatic Life Event pops; TLEQ Adequate reliability and validity - Settings, Network of Alcohol and Questionnaire (TLEQ); used in adolescents, D&A user, and prison pops - Other Drug Agencies. Trauma Screening limited empirical testing; TSQ is simple, limited Questionnaire (TSQ) empirical testing, adequate psychometrics in preliminary studies

4 Self-report SysReview of 24 PTSD Self- varied varied (have not yet acquired the book, but above M1 measures of Report Screeners reviews cite - and build upon - this work) Norris, F. H. and J. L. Hamblen civilian trauma (2004). Standardized self-report and PTSD measures of civilian trauma and PTSD. Assessing psychological 2004 trauma and PTSD. J. Wilson and T. M. Keane. New York, NY, Guilford Press: 63-102.

Individual Studies 5 Self-report Trauma History Screen (THS) 4 samples: mean 4 samples: Homeless Universal n/a Validation of brief self-report measure of trauma H2 measure of ages=45 (homeless residential Veterans; Non- exposure - assesses frequency of HMS and trauma exposure vets); 43 (hospital rehab ctr for clinical PPD, + detail on PPD events Carlson, E. B., P. A. Palmieri, et al. trauma center); vets; university community (2011). "Development and Validation 18.5 (university hospital sample in of a Brief Self-Report Measure of 2011 females); 20 years trauma center; hospital; Non- Trauma Exposure: The Trauma (community college) university; clinical History Screen." Psychological small community Assessment 23(2): 463-477. community sample (female college university students); 6 Psychometric Screen for Posttraumatic Adults (30-45) lg, private, inpatient Universal SPTSS found to be valid and reliable brief M2 Carlson, E. B. (2001). "Psychometric study of brief Stress Symptoms nonprofit admissions to screener for PTSD symptoms - epecially for study of a brief screen for PTSD: screen for PTSD psychiatric psych hospital those who may have experienced multiple Assessing the impact of multiple 2001 hospital traumatic events, who report no traumatic events, traumatic events." Assessment 8: 431- or who have not been asked about traumatic 441. events

C.3 - Clinical Literature Search Matrix 22 September 26, 2012 ONC SAMSHA TEP Results for Behavioral Health Domain – Trauma Weighted Target Population/Setting Relevance Year of Citation Pub Screening Tool or (Clinical) Risk Universal vs Targeted Evidence of Topic Measure Age Range Setting Group Screening Health Outcomes Key Findings/Implications High Med Low 7 Assessing Stressful Life Events Adults Reviews the psychometric properties of the Life L2 traumatic event Screening Questionnaire Events Screening Questionnaire, and discusses Goodman, L. A., C. Corcoran, et al. exposure the complexities of assessing trauma exposure. (1998). "Assessing traumatic event Good discussion of general challenges/issues exposure: General issues and related to asessment. preliminary findings for the Stressful 1998 Life Events Screening Questionnaire." Journal of Traumatic Stress 11: 521- 542.

8 validation of Traumatic Life Events 4 samples: mean 4 samples: SA 4 samples: SA Universal n/a Brief screener intended for use in clinical settings - M2 broad-spectrum Questionnaire ages=males 31& residential residential assess exposure to broad range of traumatic Kubany, E. S., M. B. Leisen, et al. measure of females 29 (SA program; VA program events (2000). "Development and preliminary trauma exposure program residents); vocational residents; validation of a brief broad-spectrum 51 (Vietnam vets); rehab Vietnam vets; measure of trauma exposure: The 2000 males 24& females program; undergraduates Traumatic Life Events Questionnaire." 21 university; ; "battered Psychological Assessment 12: 210- (undergraduates); support group women" 224. 20-54 ("battered for battered women") women

9 PTSD Checklist PTSD Checklist- Civilian Adults (avg. 48.9 VA Primary Female found qualitfied support for use of the PTSD- M2 Lang, A. J., C. Laffaye, et al. (2003). sensitivity version years) Care Clinic veterans Civilian version with female veterans in primary "Sensitivity and specificity of the PTSD care setting - but urged further research to find Checklist in detecting PTSD in femal 2003 optimal tool for general clinical settings veterans in primary care." Journal of Traumatic Stress 16: 257-264.

10 PTSD Checklist PTSD Checklist and SPAN Adults (Males avg. VA Primary Patients in four Found PTSD Checklist the preferred diagnostic M2 Yeager, D. E., K. M. Magruder, et al. and SPAN in VA 62 years; Females Care clinic VA medical tool, unless brevity is an issue. Suggests (2007). "Performance characteristics primary care 50 years) centers clinicians consider a lower cutoff score for the of the Posttraumatic Stress Disorder settings PTSD Checklist when used in primary care 2007 Checklist and SPAN in Veterans settings - but did not recommend different cutoffs Affairs primary care settings." General by gender or race. Hospital Psychiatry 29: 294-301.

11 Brief screening New York PTSD Risk Score Adults Trauma n/a Validation of brief screening tool for psychological H2 tool for patients trauma in clinical care setting that incorporates Boscarino, J. A., H. L. Kirchner, et al. assessing Primary Care PTSD Screen, depression (2011). "A brief screening tool for psychological symptoms, access to care, sleep disturbance, assessing psychological trauma in trauma in clinical trauma history and demographic variables clinical practice: development and 2011 care symptoms, access to care, sleep disturbance, validation of the New York PTSD Risk trauma history and demographic variable Score." General Hospital Psychiatry 33: 189-500.

12 Screener sex for 4-items from Abuse Adults ED Emergency Screener sex does not affect disclosure of IPV L2 IPV Assessment Scale Dept patients Gerlach, L. B., E. M. Datner, et al. (2007). "Does sex matter? Effect of screener sex in intimate partner 2007 violence screening." American Journal of Emergency Medicine 25: 1047- 1050.

C.3 - Clinical Literature Search Matrix 23 September 26, 2012 ONC SAMSHA TEP Results for Behavioral Health Domain – Trauma Weighted Target Population/Setting Relevance Year of Citation Pub Screening Tool or (Clinical) Risk Universal vs Targeted Evidence of Topic Measure Age Range Setting Group Screening Health Outcomes Key Findings/Implications High Med Low 13 Assessing PTSD Trauma Symptom Inventory Adults Veterans with TSI is useful measure of trauma symptoms in M2 Symptoms in TBI and/or vets who also have TBI Bahraini, N. H., L. A. Brenner, et al. Veterans PTSD (2009). "Utility of the Trauma Symptom Inventory for the Assessment of Post-Traumatic Stress 2009 Symptoms in Veterans with a History of Pscyhological Trauma and/or Brain Injury." Military Medicine 174(10): 1005-1009.

14 Test of single- 1-item PTSD screener Adults Military Health Patients in compared single-item PTSD screener with 4-item H2 item PTSD (compared with 4-item PC- Primary Care military health PC-PTSD - it failed to offer sound test Gore, K. L., C. C. Engel, et al. (2008). screener PTSD) Clinic primary care characteristics "Test of a single-item posttraumatic clinics stress disorder screener in a military 2008 primary care setting." General Hospital Psychiatry 30: 391-397.

15 Trauma Life Event Checklist, Clinician Adults Deaf persons CAPS more effective screener for PTSD in deaf M2 exposure and Administered PTSD Scale, population than TSI symptoms in Peritraumatic Distress Scale, deaf pop. Trauma Symptom Inventory, Schild, S. and C. J. Dalenberg (2012). Somatoform Diissociation "Trauma Exposure and Traumatic Questionnaire, Peabody Symptoms in Deaf Adults." Individual Achievement Test - 2012 Psychological Trauma: Theory, Revised, Interpersonal Research, Practice, and Policy 4(1): Support Evaluation list 117-127.

16 Validation of PC- PC-PTSD Screener Adults Persons with original PCD-PTSD useful screener for civilians M2 PTSD screener Substance Use with SUD van Dam, D., T. Ehring, et al. (2010). in civilian SA Disorders "Validation of the Primary Care patients Posttraumatic Stress Disorder (PC- PTSD) screening questionnaire in 2010 civilian substance use disorder patients." Journal of Substance Abuse Treatment 39: 105-113.

17 Predicting PTSD Predictive screener based on Adults Urban ED Urban ER - Universal easily implemented in clinical care setting - used H2 Richmond, T. S., J. Ruzek, et al. after injury STEPP (validated for children) presenting with to risk-stratify injury patients to predict potential (2011). "Predicting the future - adapted for adults, and minor injury PTSD development of depression or PTSD 2011 adding depression prediction after injury." General Hospital Psychiatry 33: 327-335.

18 Trauma PTSD Checklist - Civilian Adults (18-70) Primary Care - Patients comorbidity of lifetime Pts screening postive for BD were 2.6 x more M2 Neria, Y., M. Olfson, et al. (2008). exposure and Version, Life Events Scale General screening bipolar disorder and likely to report physical assault and 2.9 x more "Trauma exposure and posttraumatic PTSD in Bipolar (trauma screeners only) Medicine positive for current PTSD sign likely to screen positive for current PTSD stress disorder among primary care Patients Practice Bipolar associated with 2008 patients with bipolar spectrum Disorder impairment and poor disorder." Bipolar Disorders 10: 503- social functioning 510.

C.3 - Clinical Literature Search Matrix 24 September 26, 2012 ONC SAMSHA TEP Results for Behavioral Health Domain – Trauma Weighted Target Population/Setting Relevance Year of Citation Pub Screening Tool or (Clinical) Risk Universal vs Targeted Evidence of Topic Measure Age Range Setting Group Screening Health Outcomes Key Findings/Implications High Med Low 19 Effect of Childhood Trauma Adults (18-75) Primary Care urban, low- Use of 10-item CD-RISC self-report scale for H2 Resilience Questionnaire; Traumatic or OB-GYN at income, highly resilience can help clinicians better understand Wrenn, G. L., A. P. Wingo, et al. Events Inventory urban general traumatized, within-group differences in those with PTSD, and (2011). "The Effect of Resilience on hospital predominantly identify those with low-resilience who may benefit Posttraumatic Stress Disorder in 2011 AA men and from interventions designed to increase resilience Trauma-Exposed Inner-City Primary women, Care Patients." Journal of the National Medical Association 103(7): 560-566.

20 Relations among Life Experiences Checklist; Adults Methadone Methadone- found higher levels of supports clinical standard of assessing for trauma M2 Traumatic, Post- Primary Care PTSD Screen clinic maintenance lifetime trauma and PTSD among those in SA treatment Barry, D. T., M. Beitel, et al. (2011). Traumatic and treatment experiences among those "Exploring Relations Among Physical Pain patients with chronic severe pain Traumatic, Posttraumatic, and 2011 Experiences Physical Pain Experiences in Methadone-Maintained Patients." The Journal of Pain 12(1): 22-28.

21 Associations PTSD Module of the Adults (18-79) university- patients with possible gender examines types of pschological trauma and H3 Norman, S. B., A. J. Means- between Composite International affiliated differences in treatment specific physical illnesses assocaited with each. Christensen, et al. (2006). psychological Diagnostic Interview primary care compliance depending on For example, sexual trauma was associated with "Associations Between Psychological trauma and clinics trauma history arthritis in men and with cancer and digestive 2006 Trauma and Physical Illness in physical illness problems in women. Primary Care." Journal of Traumatic Stress 19(4): 461-470.

22 Evaluating 2 self- Impact of Events Scale; Adults (mean age Police stations Victims of crime both screeners found especially suitable because M2 report PTSD Posttraumatic Stress Disorder 48) of ease of administration - esp important in Wohlfarth, T., F. W. Winkel, et al. screeners (PTSD) Symptom situations in which no professional personnel is (2003). "Screening for Posttraumatic Scale, Self-Report version available Stress Disorder: An Evaluation of Two 2003 (PSS-SR) Self-Report Scales among Crime Victims." Psychological Assessment 15(1): 101-109.

Sexual Trauma/DV/IPV Review Studies 23 Screening Review of 14 Screeners Adults primary care, Women Universal effectievness of IPV More women in the screened group initiated H1 Women for IPV - acute care, OB- screening assessed in discussions about IPV with their clinicians, Systematic GYN clinics RCT -reduced IPV indicating at least a change in the Review recurrence, PTSD clinic visit related to screening. Nelson, H. D., C. Bougatsos, et al. reduced IPV recurrence, Screening instruments designed for healthcare (2012). "Screening Women for PTSD symptoms, and settings can accurately identify women Intimate Partner Violence: A alcohol problems and experiencing IPV. Screening..can reduce IPV and Systematic Review to Update the 2012 improved scores for improve health outcomes depending on 2004 U.S. Preventive Services Task quality of life, depression, population screened and outcomes measured Force Recommendation." Annals of and mental health, (though effectiveness trials have important Internal Medicine 156(11): 1-13. differences were not limitations). Screening has minimal adverse statistically significant effects. between groups (39).

C.3 - Clinical Literature Search Matrix 25 September 26, 2012 ONC SAMSHA TEP Results for Behavioral Health Domain – Trauma Weighted Target Population/Setting Relevance Year of Citation Pub Screening Tool or (Clinical) Risk Universal vs Targeted Evidence of Topic Measure Age Range Setting Group Screening Health Outcomes Key Findings/Implications High Med Low 24 Screening for HITS; WAST; ISA-P; PVS; Adults Ensure before implementing a Reviews these commonly used screeners and H1 IPV: State of the AAS; WEBS universal screener that the urges clinicians to understand their limitations - Science benefits outweigh the risks - though they have some utility in identifying many screeners are not maltreatment, none of the screeners have been emprically sound. Author says validated with IPV reports (e.g. police reports). Haggerty, L. A., J. W. Hawkins, et al. limitations related to the The CTS is often used in comparative studies, (2011). "Tools for Screening for psychometric properties of but it was not developed with an IPV focus. There Interpersonal Violence: State of the 2011 available screening tools is no "gold standard". Science." Violence and Victims 26(6): warrant caution and additional 725-737. evidence is needed to confirm or negate the value of universal screening in low-risk populations.

25 Screening for Abuse Assessment Screen Varied: Pre-Natal Pre-natal clinic identification of DV increased with use of M1 DV during (AAS); Conflicts Tactics Scale; Adolescents; Adults Clinic patients screener - especially repeated use throughout O'Reilly, R., B. Beale, et al. (2010). pregnancy Violence Against Women pregnancy & in questionnaire format "Screening and Intervention for Screen Domestic Violence During Pregnancy 2010 Care: A Systematic Review." Trauma, Violence, and Abuse 11(4): 190-201.

26 Sys Review of Review of 18 Tools Adults Varied Women insufficient evidence limited evidence from found HITS scale the best of several short M1 Screening (general "weak" studies screening tools for use in health-care settings Feder, G., J. Ramsay, et al. (2009). Critiera (UK practice, Eds, "How far does screening women for National urgent care, domestic (partner) violence in different Committee) DV refuges, health-care settings meet criteria for a women's screening programme? Systematic 2009 healthcare reviews of nine UK National Screening centers, Committee criteria." Health women's Technology Assessment 13(16): i- homes, ante- 136. natal clinics)

Individual Studies 27 Evaluation of VA screener for sexual trauma Adults data extracted VA patients increase in use of mh Prospective study assessing whether universal M2 Kimerling, R., A. E. Street, et al. Universal (clinical reminder) from VA screened for services by those screening for military-related sexual trauma had (2008). "Evaluation of Universal Screening clinical sexual trauma screened for sexual an impact on subsequent use of mh services Screening for Military-Related Sexual 2008 reminders trauma Trauma." Psychiatric Services 59(6): 635-640.

28 2-item screener 2 items from the Childhood Adults HMO Women 2-item screener found effective for detecting H2 for childhood Trauma Questionnaire - Short history of physical or sexual abuse in childhood - Thombs, B. D., D. P. Bernstein, et al. physical/sexual Form (CTQ-SF) developed for primary care setting (2007). "A brief two-item screener for abuse detecting a history of physical or 2007 sexual abuse in childhood." General Hospital Psychiatry 29: 8-13.

29 Systematic not named Adults varied Women Both sides of the argument are insufficient evidence of reviews literature on universal screening for IPV H2 Todahl, J. and E. Walters (2011). Review of (primarily) presented health outcomes as a "Universal Screening for Intimate Universal result of universal Partner Violence: A Systematic 2011 Screening for screening for women Review." Journal of Marital and Family IPV Therapy 37(3): 355-369.

C.3 - Clinical Literature Search Matrix 26 September 26, 2012 ONC SAMSHA TEP Results for Behavioral Health Domain – Trauma Weighted Target Population/Setting Relevance Year of Citation Pub Screening Tool or (Clinical) Risk Universal vs Targeted Evidence of Topic Measure Age Range Setting Group Screening Health Outcomes Key Findings/Implications High Med Low 30 Screener for a modified version of the Adults (18+) comparison Couples Screening instrument useful for distinguishing M2 Typologies of Revised Conflict Tactics scale - sample experiencing characterological and situational violence. (Part Friend, D. J., R. P. Cleary Bradley, et IPV CTS-2 (+screeners for alcohol recruited from situational of a larger study to assess efficacy of a workshop al. (2011). "Typologies of Intimate and drug abuse & antisocial community- violence designed to reduce couple violence.) Partner Violence: Evaluation of a 2011 personalities) based Screening Instrument for organizations, Differentiation." Journal of Family govt agencies, Violence 26: 551-563. ads

31 Intimate Justice Danger Assessment Scale Adults (19-59, community women seeking Universal Argues drawbacks associated with both DAS and M3 Scale (DAS); Revised Conflict mean 34) mental health treatment for CTS-2. Intimate Justice Scale addresses these Jory, B. (2004). "The Intimate Justice Tactics Scale (CTS-2); centers, any presenting drawbacks - focuses on ethical dynamics in Scale: An Instrument to Screen for Intimate Justice Scale medical problem (not relationships, not specific abuse. Not intended to Psychological Abuse and Physical center, private limited to DV) replace questionnaires that directly assess 2004 Violence in Clinical Practice." Journal mental health violence, but in conjunction. of Marital and Family Therapy 30(1): practices, 29-44. counseling centers, DV center 32 Screening for Woman Abuse Screening 18-64 Emergency Women n/a RCT on screening methods - sample assigned H2 IPV in Health Tool (WAST); Partner Department, written, computer-based, and verbal methods MacMillan, H. L., C. N. Wathen, et al. Care Settings Violence Screen (PVS) Family (PVS and WAST randomized within these (2006). "Approaches to Screening for Practices, groups) Women preferred self-completed Intimate Partner Violence in Health Women's approaches (over face-to-face); computer 2006 Care Settings." JAMA Journal of the Health Clinic screening did not increase prevalence; written American Medical Association 296(5): screens had fewest missing data. PVS and 530-536. WAST highly comparable.

33 Optimal Methods Partner Violence Screen Adults (mean age Urban, Men and PVS and HITS chosen for practicality in a busy H2 and Screeners (PVS); Hurts, Insults, 43.9) Academic, Women internal medicine practice, validation in similar Kapur, N. A. and D. M. Windish for IPV Threatens and Screams Internal study populations, and correlation with the (2011). "Optimal Methods to Screen (HITS) Medicine previously validated 19-item Conflict Tactics Men and Women for Intimate Partner Residency Scale. Study found prevalence higher for self- Violence: Results from an Internal 2011 Continuity report (over face-to-face) for women, but Medicine Residency Continuity Clinic." Clinic methods ns for men; PVS had higher prevalence Journal of Interpersonal Violence than HITS but HITS has potential to capture 26(2): 2335-2352. greater variety of IPV

Childhood Violence/ Adverse Childhood Events

Review Studies 34 Review of multiple screeners/ measures 0-6 varied young children Assessment measures of trauma symptoms and M1 Measures PTSD in young children lack a measure that Stover, C. S. and S. Berkowitz (2005). assessing includes are critical components. Some of the "Assessing Violence Exposure and violence parent checklist measures show promise. Trauma Symptoms in Young Children: exposure and 2005 A Critical Review of Measures." trauma Journal of Traumatic Stress 18(6): symptoms in 707-717. young children

C.3 - Clinical Literature Search Matrix 27 September 26, 2012 ONC SAMSHA TEP Results for Behavioral Health Domain – Trauma Weighted Target Population/Setting Relevance Year of Citation Pub Screening Tool or (Clinical) Risk Universal vs Targeted Evidence of Topic Measure Age Range Setting Group Screening Health Outcomes Key Findings/Implications High Med Low 35 PTSD in UCLA PTSD Reaction Index 0-18 Primary Care children/youth "a move towards universal UCLA PTSD RI is most common, but not used H1 Pediatric (UCLA PTSD RI); Child (general) screening of some sort should universally - there is an abbreviated version (9 Trauma Patient Trauma Screening be the primary goal" items); CTSQ outperformed CIES in predicting Questionnaire (CTSQ); PTSD; STEPP developed specifically for use in Children's Impact of Events acute trauma settings (feasibility tested for brevity Scale (CIES); Screening Tool and simplicity in administering and scoring). Makley, A. T. and R. A. J. Falcone for Early Predictors of PTSD Authors suggest continued evaluation and (2010). "Posttraumatic Stress (STEPP); Pediatric Symptoms research is needed to determine which screening Disorder in the Pediatric Trauma 2010 Checklist (PSC) tool is the most reliable, but say even with Patient." Seminars in Pediatric adequate screening children are not accessing Surgery 19: 292-299. the follow-up treatment they need. And, Even with an ideal screening tool, determining which group of health care workers are best suited to screen children is not clear.

Individual Studies 36 Screening for Child Behavior Checklist - Children 1.5-5 MH Center children CBCL-PTSD subscale is not useful in screening H2 PTSD in young PTSD subscale years attending for PTSD as it failes to adequately discriminate Loeb, J., E. M. Stettler, et al. (2011). children Mental Health between young children with PTSD and children "The Child Behavior Checklist PTSD center with other psychiatric and behavioral symptoms Scale: Screening for PTSD in Young 2011 Children with High Exposure to Trauma." Journal of Traumatic Stress 24(4): 430-434.

37 Prediction of Child Behavior Checklist; Children (avg. 10.4 Level I Trauma Children and discusses DSM-IV algorithm threshold M2 Scheeringa, M. S., M. J. Wright, et al. PTSD in DSM-IV years) Center their parents differences for criteria B, C, D for various age (2006). "Factors Affecting the Children and seeking groups. suggests possible underreporting of Diagnosis and Prediction of PTSD Adolescents services in a symptoms when child or parent is interviewed, 2006 Symptomatology in Children and Level I trauma but not both. General discussion of inherent Adolescents." The American Journal center challenges of assessing trauma in younger of Psychiatry 163(4): 644-651. children.

38 Assessment and Stressful Life Events Adults n/a n/a "ethical imperative for nurses to n/a authors suggest screeners (listed under H2 Response to Screening Questionnaire; ask about ACE" "screening tools/measures) can and should be ACEs Primary Care PTSD Screen; used by clinicians to assess for ACEs at varied Impact of Event Scale- entry points into health services; should be used Waite, R., P. Gerrity, et al. (2010). Revised; Life Stressor for men and women regardless of demographic "Assessment for and Response to Checklist - Revised; Short or relational circumstances Adverse Childhood Experiences." 2010 Form of the PTSD Checklist Journal of Psychosocial Nursing Civilian Version; Childhood 48(12): 51-61. Trauma Questionnaire Short Form

39 Linking Child Traumatic Events Screening 0-6 (TESI-PRR); 0- none specified Children Screeners intended to be purpose of the paper is to provide guidance to M2 Welfare and MH Inventory - Parent Report 18 (CPTSD-RI); 0- experiencing universal Child Welfare workers to integrate trauma Conradi, L., J. Wherry, et al. (2011). using Trauma (TESI-PFR-R); UCLA Child 18 (TSCC); 3-12 trauma screening, assessment, and evaluation into child "Linking Child Welfare and Mental Screening and PTSD Reaction Index (TSCYC) welfare and MH services - reviews commonly Health Using Trauma-Informed Assessment (CPTSD-RI); Trauma used tools for each 2011 Screening and Assessment Symptom Checklist for Practices." Child Welfare 90(6): 129- Children (TSCC); Trauma 147. Symptom Checklist for Young Children (TSCYC)

C.3 - Clinical Literature Search Matrix 28 September 26, 2012 ONC SAMSHA TEP Results for Behavioral Health Domain – Trauma Weighted Target Population/Setting Relevance Year of Citation Pub Screening Tool or (Clinical) Risk Universal vs Targeted Evidence of Topic Measure Age Range Setting Group Screening Health Outcomes Key Findings/Implications High Med Low Screening Behaviors of Primary Care Providers: Associated Factors

40 Screening for n/a n/a n/a n/a Universal examines physician knowledge, attitudes, and H3 Childhood practices about screening for childhood abuse Trauma in Adult histories - most rarely or never screened Weinreb, L., J. A. Savageau, et al. PC Patients (2010). "Screening for Childhood Trauma in Adult Primary Care 2010 Patients: A Cross-Sectional Survey." The Primary Care Companion to the Journal of Clinical Psychiatry 12(6).

41 Assessment and multiple discusses nurses' screening behaviors for child M3 Waite, R., P. Gerrity, et al. (2010). Response to abuse, and guidelines for clinicians for screening "Assessment for and Response to ACEs for and responding to disclosure of childhood Adverse Childhood Experiences." 2010 abuse Journal of Psychosocial Nursing 48(12): 51-61.

42 PC-PTSD PC-PTSD Adults Primary Care n/a Provides guidelines for primary care clinicians to H3 Guidelines (general) use the PC-PTSD screener and respond to Prins, A., R. Kimerling, et al. (1999). positive results The Primary Care PTSD Screen (PC- PTSD). 15th Annual Meeting of the 1999 International Society for Traumatic Stress Studies. Miami, FL.

43 Review of multiple Young children (0-6 discusses challenges associated with screening M3 Measures years) young children for trauma symptoms Stover, C. S. and S. Berkowitz (2005). assessing "Assessing Violence Exposure and violence Trauma Symptoms in Young Children: exposure and 2005 A Critical Review of Measures." trauma Journal of Traumatic Stress 18(6): symptoms in 707-717. young children

44 Primary Care n/a Adults Primary care n/a qualitative study on PC providers' experiences L3 providers' (general) and strategies in working with trauma patients Green, B. L., S. Kaltman, et al. (2011). experiences with "Primary Care Providers' Experiences trauma patients with Trauma Patients: A Qualitative 2011 Study." Psychological Trauma: Theory, Research, Practice, and Policy 3(1): 37-41.

45 DV assessments non-specific Adults Child n/a assesses frequency, methods and practices of M3 in child Advocacy universal DV assessments in CACs - <1/3 do Thackeray, J. D., P. V. Scribano, et al. advocacy center Centers universal assessments, and often inadequately (2010). "Domestic violence assessments in the child advocacy 2010 center." Child Abuse and Neglect 34: 172-182.

C.3 - Clinical Literature Search Matrix 29 September 26, 2012 ONC SAMSHA TEP Results for Behavioral Health Domain – Trauma Weighted Target Population/Setting Relevance Year of Citation Pub Screening Tool or (Clinical) Risk Universal vs Targeted Evidence of Topic Measure Age Range Setting Group Screening Health Outcomes Key Findings/Implications High Med Low 46 Practical WAST Adults Primary care Women Universal acts of disclosure alone is describes how primary care providers can H3 approaches to (general) thereapeutic if done overcome common barriers to screening for IPV - Terebelo, S. (2006). "Practical screening for correctly specific strategies provided for screening and approaches to screening for domestic IPV response to positive screens violence." JAAPA Journal of the 2006 American Academy of Physician Assistants 19(9): 30-35.

47 Screening for non-specific Adults Primary Care Women Universal general: Appropriate Cites research supporting universal screening; H3 DV in healthcare (general) screening and describes training for nurses to assist in IPV Roark, S. V. (2010). "Intimate Partner settings interventions will benefit screening Violence: Screening and Intervention victims of IPV" in the Health Care Setting." Journal of 2010 Continuing Education in Nursing 41(11): 490-495.

48 Screening for Woman Abuse Screening 18-64 Emergency Women n/a RCT on screening methods - sample assigned H3 IPV in Health Tool (WAST); Partner Department, written, computer-based, and verbal methods MacMillan, H. L., C. N. Wathen, et al. Care Settings Violence Screen (PVS) Family (PVS and WAST randomized within these (2006). "Approaches to Screening for Practices, groups) Women preferred self-completed Intimate Partner Violence in Health 2006 Women's approaches (over face-to-face); computer Care Settings." JAMA Journal of the Health Clinic screening did not increase prevalence; written American Medical Association 296(5): screens had fewest missing data. PVS and 530-536. WAST highly comparable.

C.3 - Clinical Literature Search Matrix 30 September 26, 2012 ONC SAMSHA TEP Results for Behavioral Health Domain – Trauma Time to Admin. Corresponds to DSM-IV Screens for PTSD # of items Allows Multiple Trauma Criteria (in min.) BAI-PC 7 3 Yes N/A Primary Care PTSD Screen (PC-PTSD) 4 2 Yes N/A Short Form of the PTSD Checklist 6 2 Yes N/A Short Screening Scale for PTSD 7 3 Yes N/A SPAN 4 2 Yes N/A SPRINT 8 3 Yes N/A Trauma Screening Questionnaire (TSQ) 10 4 Yes N/A PTSD Checklist (PCL) 17 5 to 10 Yes Yes

Assesses DSM-IV Trauma Exposure Measures Target Group Format # of items Time to Administer (minutes) Criterion A Combat Exposure Scale (CES) Adult Self-Report 7 5 No Evaluation of Lifetime Stressors (ELS) Adult Self-Report and Interview 56 60-360 Yes

Life Events Checklist (LEC) Adult Self-Report 17 5 to 10 No Life Stressor Checklist-Revised (LSC-R) Adult Self-Report 30 15-30 Yes Potential Stressful Events Interview (PSEI) Adult Interview 62 120 Yes Stressful Life Events Screening Questionnaire (SLESQ) Adult Self-Report 13 10 to 15 No

Trauma Assessment for Adults (TAA) Adult Self-Report and 17 10 to 15 A-1 only Interview Trauma History Screen (THS) Adult Self-Report 13 2 to 5 Yes Trauma History Questionnaire (THQ) Adult Self-Report 24 10 to 15 A-1 only Traumatic Events Questionnaire (TEQ) Adult Self-Report 13 5 A-1 only Traumatic Life Events Questionnaire (TLEQ) Adult Self-Report 25 10 to 15 A-1 only Trauma History Questionnaire (THQ) Adult Self-Report 24 10 to 15 Yes Traumatic Stress Schedule (TSS) Adult Interview 9 5 to 30 A-1 only

lt PTSD Self-Report Measures Time to Admin. Corresponds to DSM-IV # of items Allows Multiple Trauma (in min.) Criteria Davidson Trauma Scale (DTS) 17 10 to 15 No Yes Distressing Event Questionnaire (DEQ) 35 10 to 15 Yes Yes Impact of Event Scale-Revised (IES-R) 22 5 to 10 No Yes Los Angeles Symptom Checklist (LASC) 43 10 to 15 Yes No Mississippi Scale for Combat-Related PTSD (M-PTSD) 17 10 to 15 Yes No

Modified PTSD Symptom Scale (MPSS-SR) 17 10 to 15 Yes Yes Penn Inventory for Posttraumatic Stress Disorder (Penn 26 15-20 Yes No Inventory) Posttraumatic Diagnostic Scale (PDS) 49 10 to 15 No Yes PTSD Checklist (PCL) - Civilian, Military, Specific Trauma 17 5 to 10 Yes Yes

Screen for Posttraumatic Stress Symptoms (SPTSS) 17 10 to 15 Yes Yes

Trauma Symptom Checklist-40 (TSC-40) 40 10 to 15 Yes No Trauma Symptom Inventory (TSI) 100 15-20 Yes No

Target Child Measures Format # of items Time to Admin. (min.) Allows Multiple Trauma Corresponds to DSM-IV Criteria Age Group Child PTSD Reaction Index*(CPTS-RI) 6 to 17 Interview 20 15-20 No No Child PTSD Symptom Scale (CPSS) 8 to 18 Self-Report 26 10 to 15 Yes Yes Childhood PTSD Interview n.s. Interview 93/1 15-20 Yes Yes Children's Impact of Traumatic Events Scale- 6 to 18 Interview 78 30-45 Yes Yes Revised (CITES-2) Children's Posttraumatic Stress Disorder Inventory 7 to 18 Interview 43/1 15-20 Yes Yes (CPTSDI) Clinician-Administered PTSD Scale for Children & 7 to 18 Interview 33/2 30-120 Yes Yes Adolescents (CAPS-CA) CPTS-RI Revision 2 (aka PTSD Index for DSM-IV) 6 to 17 Interview 20 15-20 No No Dimensions of Stressful Events (DOSE) n.s.* Interview 24/varies 15-30 Yes Yes My Worst Experiences Survey 10 to 18 Self-Report 105 20-30 No Yes Parent Report of Child's Reaction to Stress n.s. Parent Report 79 30-45 Yes No Trauma Symptom Checklist for Children (TSCC) 6 to 17 Interview 54/1 10 to 20 Yes No Trauma Symptom Checklist for Young Children 3 to 12 Caregiver-report 54/1 20-30 Yes No (TSCYC) Traumatic Events Screening Inventory*(TESI) 4 and up Interview 18/varies 10 to 30 Yes Yes UCLA PTSD Index for DSM-IV 7-12 child, Self-Report 48 15-20 Yes Yes 13+ adol When Bad Things Happen Scale (WBTH) 8 to 13 Self-Report 95/1 10 to 20 No Yes

C.3 - Clinical Literature Search Matrix 31 September 26, 2012 ONC SAMSHA TEP Results for Behavioral Health Domain – Trauma Stressful Life Events Screening Questionnaire (Goodman, Corcoran, Turner, Yuan, & Green, 1998). A 26-question standardized instrument measuring exposure to all possible kinds of traumas, including sexual and physical assault, witnessing violence, combat trauma, illness, accidents, traumatic deaths, and natural disasters; test-retest reliability (median Cronbach’s alpha coefficient = 0.73) and convergent validity (median Cronbach’s alpha coefficient = 0.64). Primary Care PTSD Screen (Prins et al., 1999) A 4-question instrument measuring symptoms of trauma during the past month; sensitivity = 0.91 and specificity = 0.72. Impact of Event Scale–Revised (Weiss & Marmar, 1997) A 22-item questionnaire developed and based on DSM-IV criteria; reported internal consistency ranges from 0.79 to 0.92. Life Stressor Checklist–Revised (Wolfe & Kimmerling, 1997) A 30-item instrument measuring lifetime exposure to stressful events; Cronbach’s alpha coefficient = 0.70. Short Form of the PTSD Checklist-Civilian Version (Lang & Stein, 2005) A 6-item instrument empirically derived from the 17-item PTSD Checklist-Civilian Version for use in primary care settings; Cronbach’s alpha coefficient = 0.79. Childhood Trauma Questionnaire-Short Form (Bernstein & Fink, 1998) A 28-item retrospective self-report questionnaire designed to assess five dimensions of childhood maltreatment; reliability for each of the scales across physical abuse = 0.83 to 0.86, emotional abuse = 0.84 to 0.89, sexual abuse = 0.92 to 0.95, physical neglect = 0.61 to 0.78, and emotional neglect = 0.85 to 0.91. Measures for Children Under 6 for potential trauma and PTSD symptoms Trauma Exposure Symptom Inventory - Parent Report (TESI-PR) TESI-PRR = Traumatic Events Screening Inventory–Parent Report Revised; VEX-PV = Violence Exposure Scale–Preschool Version; VEX-PR = Violence Exposure Scale–Parent Report; CBCL = Child Behavior Checklist PTE=Potentially Traumatic Event CBCL = Child Behavior Checklist CSBI = Child Sexual Behavior Inventory TSCYC=Trauma Symptom Checklist for Young Children IBI = Interbeat Interval PT-SIC = Posttraumatic Symptoms Inventory for Children PTSD-PAC = Posttraumatic Stress Disorders in Preschool Aged Children PAPA = Preschool Aged Psychiatric Assessment; TSCC = Trauma Symptom Checklist CDC = Child Dissociative Checklist

Interpersonal Violence/Domestic Violence

Hurts, Insults, Threatens, and Screams (HITS) Scale - Sherin, Sinacore, Li, Zitter, & Shakil, 1998 (designed specifically for primary care) Women's Experience with Battering Scale (WEBS) Ongoing Violence Assessment Tool (OVAT) Index of Spouse Abuse - Physical (ISA-P) Woman Abuse Screening Tool (WAST) Conflict Tactics Scale (3 versions: CTS, CTS-2, CTS2S) - used primarily for research purposes, not clinical Danger Assesment Scale (DAS) Campbell, 1995 Partner Violence Screen (PVS) Feldhaus et al., 1997 (developed and validated in ERs) Abuse Assessment Screen (AAS) Norton, Peiper, Zierler, Lima, & Hume, 1995 Ongoing Abuse Screen (OAS) Weiss, Ernst, Cham, & Nick, 2003 Index of Spouse Abuse (ISA) Hudson & McIntosh, 1981 - designed to monitor IPV over time GET SAFFEER (Lewis O-Connor 2007)

C.3 - Clinical Literature Search Matrix 32 September 26, 2012 ONC SAMSHA TEP Results for Behavioral Health Domain – Trauma IPV Screening - Debate over Utility of Universal Screening Todahl&Walter 2011 A rapidly increasing number of professional associations now recommend universal screening. They include, in part: the American Medical Association (AMA); the American Academy of Pediatrics Committee on Child Abuse and Neglect (1998); the American College of Obstetricians and Gynecologists; the American Academy of Family Physicians; the American College of Nurse Midwives; the American College of Emergency Physicians; and the American Academy of Nurse Practitioners. Among U.S. mental health professional associations, only the National Association of Social Workers (2002) and the American Psychological Association (2002) recommend universal screening. The American Association for Marriage and Family Therapy has not issued a recommendation or practice guidelines specific to IPV universal screening. The specific guidelines and recommendations urged by these organizations vary—though taken together they generally recommend that providers routinely screen all female patients for IPV (Jonassen & Mazor, 2003; McCloskey & Grigsby, 2005). The AMA (1992) encourages physicians to screen universally; their policy equates universal screening with prevention, preferring proactive procedures over a wait-and-see strategy that inquires about IPV only when signs or symptoms of violence emerge (Nelson, Nygren, McInerney, & Klein, 2004). The National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings (FVPF, 2004) recommends screening all adult and adolescent female patients; male patients are screened ‘‘when indicated.’’ Although many professional associations and organizations now recommend universal screening, others have argued either that universal screening is not appropriate or that existing evidence for the merits of screening is inconclusive. Ramsay, Richardson, Carter, Davidson, and Feder (2002) argued that as insufficient evidence exists to verify whether screening is associated with improved health outcomes for women, it is ‘‘premature to introduce a screening program for domestic violence in health care settings’’ (p. 12). Others have argued that it is not known whether screening leads to a decline in abuse and, therefore, screening at this time is not warranted (Nelson et al., 2004). The U.S. Preventive Services Task Force (USPSTF) found that the risks and benefits of screening are yet to be confirmed by rigorously designed clinical studies and, therefore, the USPSTF could not recommend for or against routine screening (Berg, 2004). Others argue that screening should only be conducted when physicians and midwives have received education about abuse and have enough knowledge about local resources to be able to respond appropriately (Webster & Holt, 2004). Ramsay et al. (2002), in their review of the screening outcome literature, ‘‘found little evidence for the effectiveness of interventions in medical settings with women who are identified by screening programs’’ (p. 10). Others have drawn similar conclusions (e.g., Nelson et al., 2004; Wathen & MacMillan, 2003).

Nelson et al 2012 Routine screening for IPV in health care settings could identify women at risk and lead to interventions that reduce violence and improve health outcomes. New recommendations from the Institute of Medicine (27), as well as recommendations from professional organizations (28– 30), support screening. Screening by health care professionals is generally acceptable to women under conditions that are perceived as private and safe and when women are asked questions in a comfortable manner, although there is no consensus about the optimal screening setting or method (31).

Feder, et al. 2009 (UK) Currently there is insufficient evidence to implement a screening programme for partner violence against women either in health services generally or in specific clinical settings.

Terebolo 2006 many professional medical organizations endorse and recommend screening, including ACEP, the American College of Obstetricians and Gynecologists, American Academy of Family Physicians, American Medical Association, American College of Physicians, and American Academy of Pediatrics, actual screening rates by health care providers remain dismal. This is discouraging because prevalence studies suggest that at least 1 in 5 female patients in the primary care setting have been victims of IPV at some point in adulthood.13 Health care providers are uniquely positioned to intervene.

American Academy of Pediatrics 2010 Looking for signs of intimate partner violence between parents of pediatric patients may or may not help the parents, but the effects of that violence on children are so profound that physicians must ask about it, a clinical report from the American Academy of Pediatrics concludes. The lead author of the report, Dr. Jonathan D. Thackeray, highlighted it in a plenary session at the academy's national meeting because the recommendations didn't get the attention they deserved when published earlier this year, he said (Pediatrics 2010; 125:1094-100).

Screening for Childhood Abuse Histories no published guidelines exist for how and under what conditions adults should be screened for childhood abuse histories in primary care settings. This is remarkable, considering Springer et al. (2003) reported that 20% to 50% of patients in adult Waite et al. 2010 primary care settings have a history of physical or sexual abuse.

C.3 - Clinical Literature Search Matrix 33 September 26, 2012 ONC SAMSHA TEP Results for Behavioral Health Domain – Trauma Summary Comments: Trauma Domain

. This scan focused on trauma-screeners that fall into three broad categories: Trauma Exposure (general)/PTSD (omits screeners specific to veteran populations and experiences); Interpersonal Violence; and Childhood Violence

PTSD/Trauma Exposure (non-Veteran-specific)

. Studies have shown PTSD is diagnosed only about 50% of the time – and less for those with co- occurring disorders – so there is good consensus that a screener would be useful. . Gold standards are clinician-administered assessments such as the Clinician-Administered PTSD Scale (Blake et al., 1995) and the Structured Clinical Interview for DSM-IV, PTSD module (First, Spitzer, Gibbon, &Williams, 1996). Use of these in clinical practice is limited by length and need for administration by a trained clinician. . There are a wide range of self-report PTSD measures (one recent review identified 41) but results vary. Though no “gold standard” among self-report tools, the Impact Events Scale (IES), PTSD Checklist – Civilian Version, Trauma Screening Questionnaire (TSQ), and Self-Report Inventory of PTSD have best diagnostic properties.

Interpersonal Violence

. Though a large (and growing) number of professional organizations recommend universal screening for IPV (especially for women), there is not consensus that this is appropriate and/or that there is sufficient evidence to warrant universal screening. (see third tab in spreadsheet for specific studies/comments) The American Academy of Pediatrics weighed in that IPV screening is critical due to effects on children. . There is no “gold standard” screener – all have limitations on psychometric properties. In healthcare settings, the HITS screener is considered the best by many researchers.

Childhood Violence/PTSD

. A large proportion (20-50%) of adults in primary care settings have histories of child physical or sexual abuse, but there are no agreed-upon guidelines for screening, nor consensus on which group of healthcare workers would be most appropriate to screen. . Again, no “gold standard” screener –more research and evaluation needed to determine which screener is most reliable. . The UCLA PTSD Reaction Index is used most commonly (though by no means universally). Child Trauma Screening Questionnaire (CTSQ) performs better than others in predicting PTSD, but Screening Tool for Early Predictors of PTSD (STEPP) was developed specifically for use in acute trauma settings and offers brevity and simplicity.

C.4 - Clinical Literature Search Summary 34 September 26, 2012 ONC SAMSHA TEP Results for Behavioral Health Domain – Trauma Acronyms

AHRQ Agency for Healthcare Research and Quality ASPE Assistant Secretary for Planning and Evaluation BH Behavioral Health BHeM BH eMeasure CDC Centers for Disease Control and Prevention CEO Chief Executive Officer CQAIMH Center for Quality Assessment and Improvement in Mental Health CQM Clinical Quality Measure CMS Centers for Medicare and Medicaid Services FACP Fellow, American College of Physicians FASAM Fellow, American Society of Addiction Medicine EDC Education Development Center EHR Electronic Health Record HITECH Health Information Technology for Economic and Clinical Health Act of 2009 HITPC Health Information Technology Policy Committee HITS Hurts, Insults, Threatens, and Screams HRSA Health Resources and Services Administration IES Impact Events Scale IHS Indian Health Service ICSI Institute for Clinical Systems Improvement IPV Interpersonal Violence/ Intimate Partner Violence IT Information Technology MD Medical Doctor MPH Masters in Public Health MSW Masters in Social Work NIAAA National Institute on Alcohol Abuse and Alcoholism NICHD National Institute of Child Health and Health Development NIDA National Institute on Drug Abuse

ONC SAMSHA TEP Results for Behavioral Health Domain – Trauma 35 by The MITRE Corporation NIH National Institutes of Health NIMH National Institute of Mental Health NINR National Institute of Nursing Research NIST National Institute of Standards and Technology NCBDDD National Center on Birth Defects and Developmental Disabilities NORC National Organization for Research at the University of Chicago NQMC National Quality Measures Clearinghouse NPRM Notice of Proposed Rulemaking NQF National Quality Forum ONC Office of the National Coordinator for Health Information Technology ONDIEH Office of Noncommunicable Disease, Injury and Environmental Health PC Primary Care PhD Doctorate of Philosophy PHQ Patient Health Questionnaire PRO Patient Recorded Outcome PROMIS Patient Reported Outcomes Measurement Information System PsyD Doctor of PTSD Post-Traumatic Stress Syndrome RHI Resolution Health, Inc. SAMHSA Substance Abuse and Mental Health Services Administration ScD Doctor of Science TEP Technical Evaluation Panel TJC The Joint Commission TSQ Trauma Screening Questionnaire US United States of America USPSTF United Stated Preventative Services Task Force VA Department of Veterans Affairs VHA Veterans Health Administration VP Vice President

ONC SAMSHA TEP Results for Behavioral Health Domain – Trauma 36 by The MITRE Corporation